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r <br /> Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 e 1210 218 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: --1 Q 2,, 'Q Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: vt "�-CfAet � CCL/yt Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> l t -�cv a tG f(ems f- \-0r � _ <br /> Phys_lca�Address ( ��L/L <br /> Inspection Date <br /> I A Time In Time Out <br /> Bin se_R p—_..__ itle — - B-AfrA-- —&AM <br /> Sc l `�'�Gl.�'l�1Si2�1 p2 1')' 0 PM 5- 0 O PM <br /> G1_51 ifS4 E_SfiYnw_bV � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' � �, l 40 Active Q Passenger 0 Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR ® End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other 7F6,Ae,' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 46 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> . Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date a / M11 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q 1 Q 1Other:§ - - - <br /> Comments <br /> 019 <br /> Inspection Form Included: O <br /> Comments Included: 1O AWZVr3 <br /> ga'Oness Rep' Signature Phone Number I sp to ig ture Phone Number <br /> INSTRUCTION BACK Correct: Incorrect: ® � E X A P L E 1 2 3 62081 <br /> ON <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />